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Patient Notice of Privacy Practices

THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED and DISCLOSED and HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY.

Our organization uses your Protected Health Information or Private Information1 collectively referred to as “Protected Health Information”) for your treatment, to obtain payment for our services and for our operational purposes, such as improving the quality of care we provide to you. We are committed to maintaining your confidentiality and protecting your health information. We are required by law to provide you with this Notice which describes our health information privacy practices and those of our affiliated health care providers. This Notice applies to all information and records related to your care that our organization workforce members and Business Associates (described below) have received or created. It also applies to health care professionals, such as physicians, and organizations that provide care to you. It informs you about the possible uses and disclosures of your Protected Health Information and describes your rights and our obligations regarding your Protected Health Information.

We are required by law to:

Maintain the privacy of your Protected Health Information;

Provide you with this detailed Notice of our legal duties and privacy practices relating to:

Your Protected Health Information; and

Abide by the terms of the Notice that are currently in effect. We reserve the right to

Change the terms of this Notice, and will notify you or your personal representative

By letter if we make any material changes to the Notice.

I. WITH YOUR CONSENT WE MAY USE and DISCLOSE YOUR PROTECTED HEALTH INFORMATION FOR TREATMENT, PAYMENT and HEALTH CARE OPERATIONS

You will be asked to sign a Consent allowing us to use and disclose your Protected Health Information to others to provide you with treatment, obtain payment for our services, and run our health care operations. Our organization will initially limit its use and disclosure or request of the

Private Information refers to unencrypted personal information in combination with any one or more of the following data elements: 1) social security number, 2) driver’s license or non-driver identification card number, or 3) account number, credit or debit card number, in combination with any required security or access code which would permit access to an individual’s financial account patient’s Protected Health Information, to the extent practicable, to a limited data set (a limited data set does not include your direct identifiers) or, if needed, to the minimum necessary to accomplish the intended purpose of such use, disclosure or request. Here are examples of how we may use and disclose your health information.

For Treatment. Our staff and affiliated health care professionals may review and record information in your record about your treatment and care. We will use and disclose this health information to health care professionals in order to treat and care for you. For example, a nurse may consult with another nurse located at another location to determine how to best treat you.

For Payment. Our Agency may use and disclose your Protected Health Information to others in order for the Agency to bill for your health care services and receive payment. For example, we may include your health information in our claim to your insurance company, Medicare or Medicaid in order to receive payment for services provided to you. We may also disclose your health information to other health care providers so that they can receive payment for your services.

For Health Care Operations. We may use and disclose your Protected Health Information to others for our organizations business operations. For example, we may use Protected Health Information to evaluate our organization services, including the performance of our staff, and to educate our staff.

II. WE MAY USE and DISCLOSE YOUR PROTECTED HEALTH INFORMATION FOR OTHER SPECIFIC PURPOSES

Business Associates

We may share your Protected Health Information with our vendors and agents who help us with obtaining payment or carrying out our business functions. These are called our “Business Associates.” For example, we may give your health information to a billing company to assist us with our billing for services, or to a law firm or an accounting firm that assists us in complying with the law and or improving our services. To protect and safeguard your health information, we require our Business Associates to appropriately safeguard your information.

Family and Friends Involved in Your Care. Unless you object, we may disclose your Protected Health information to a family member or close personal friend, including clergy, who is involved in your care or payment for that care.

Disaster Relief. We may disclose your Protected Health Information to an organization assisting in a disaster relief effort.

Public Health Activities. We may disclose your Protected Health Information for public health activities including the reporting of disease, injury, vital events, and the conduct of public health surveillance, investigation and/or intervention. We may also disclose your information to notify a person who may have been exposed to a communicable disease or may otherwise be at risk of contracting or spreading a disease or condition if a law permits us to do so.

Health Oversight Activities. We may disclose your Protected Health Information to health oversight agencies authorized by law to conduct audits, investigations, inspections and licensure actions or other legal proceedings. These agencies provide oversight for the Medicare and Medicaid programs, among others.

Reporting Victims of Abuse, Neglect or Domestic Violence. If we have reason to believe that you have been a victim of abuse, neglect or domestic violence, we may use and disclose your Protected Health Information to notify a government authority if required or authorized by law, or if you agree to the report.

Law Enforcement. We may disclose your Protected Health information for certain law enforcement purposes or other specialized governmental functions. Judicial and Administrative Proceedings. We may disclose your Protected Health Information in the course of certain judicial or administrative proceedings.

Research. In general, we will request that you sign a written authorization before using your Protected Health Information or disclosing it to others for research purposes. However, we may use or disclose your health information without your written authorization for research purposes provided that the research has been reviewed and approved by a special Privacy Board or Institutional Review Board.

Coroners, Medical Examiners, Funeral Directors, Organ Procurement Organizations. We may release your health information to a coroner, medical examiners, funeral director or, if you are an organ donor, to an organization involved in the donation of organs and tissue.

To Avert a Serious Threat to Health or Safety. We may use and disclose your Protected Health Information when necessary to prevent a serious threat to your health or safety or the health or safety of the public or another person. However, any disclosure would be made only to someone able to help prevent the threat.

Military and Veterans. If you are a member of the armed forces, we may use and disclose your Protected Health Information as required by military command authorities. We may also use and disclose Protected Health Information about foreign military personnel as required by the appropriate foreign military authority.

Workers’ Compensation. We may use or disclose your Protected Health Information to comply with laws relating to workers’ compensation or similar programs.

National Security and Intelligence Activities; Protective Services. We may disclose health information to authorized federal officials who are conducting national security and intelligence activities or as needed to provide protection to the President of the United States, or other important officials.

As Required By Law. We will disclose your Protected Health Information when required by law to do so.

III. YOUR AUTHORIZATION IS REQUIRED FOR OTHER USES OF YOUR PROTECTED HEALTH INFORMATION

We will use and disclose your Protected Health Information other than as described in this Notice or required by law only with your written Authorization. You may revoke your Authorization to use or disclose Protected Health Information in writing, at any time. To revoke your Authorization, contact the Medical Records/Health Information Management (HIM) staff. If you revoke your Authorization, we will no longer use or disclose your Protected Health Information for the purposes covered by the Authorization, except where we have already relied on the Authorization.

Marketing

The organization is required by law to receive your written authorization before we use of disclose your health information for marketing purposes. Under no circumstances will we sell our patient lists or your health information to a third party without your prior written authorization.

IV. YOUR RIGHTS REGARDING YOUR HEALTH INFORMATION

You have the following rights with respect to your health information. If you wish to exercise any of these rights, you should make your request to the Medical Records/HIM Director.

Right of Access to Protected Health Information. You have the right to request, either orally or in writing, to inspect and obtain a copy of your Protected Health Information, subject to some limited exceptions. If available, you have the right to access your information in electronic format. We must allow you to inspect your records within 10 days of your request. If you request copies of the records, we must provide you with copies within a reasonable time but not more than 30 days if the records are maintained onsite or 60 days if the records are maintained off-site. We may charge a reasonable fee for our costs in copying and mailing your requested information or the provision of information in electronic format.

In certain limited circumstances, we may deny your request to inspect or receive copies. If we deny access to your Protected Health Information, we will provide you with a summary of the information, and you have a right to request review of the denial. We will provide you with information on how to request a review of our denial and how to file a complaint with us or the Secretary of the Department of Health and Human Services.

Right to Request Restrictions. You have the right to request restrictions on the way we use and disclose your Protected Health Information for our treatment, payment or health care operations. You also have the right to request restrictions on our disclosures of your Protected Health Information to a family member, friend or other person who is involved in your care or the payment for your care.

We may not be required to agree to your requested restriction, and in some cases, the law may not permit us to accept your restriction. However, if we do agree to accept your restriction, we will comply with your restriction in most situations. We may not be permitted to honor your restriction(s) in the following situations: (1) if you are being transferred to another health care institution, (2) the release of records is required by law, (3) the release of information is needed to provide you emergency treatment, or (4) in the case of licensed home care services agencies, the release is required by a third party payor contract. If your restriction applies to the disclosure of information to a health plan for purposes of payment or health care operations (and not for treatment) where you paid out of pocket in full for items or services, we are required to honor that request.

Right to Receive Notice of a Breach. You have the right to receive notification by first class mail or by e-mail (if you have indicated a preference to receive information by e-mail), of any breaches of Unsecured Protected Health Information as soon as possible, but in any event, no later than 60 days following the discovery of the breach. A “Breach” means the unauthorized access, acquisition, use, or disclosure of Protected Health Information which compromises the security or privacy of Protected Health Information, except where an unauthorized person to whom such information is disclosed would not have reasonably been able to retain such information.

“Unsecured Protected Health Information” is information that is not secured through the use of a technology or methodology identified by the U.S. Department of Health and Human Services to render the Protected Health Information unusable, unreadable and undecipherable to unauthorized users. The notice is required to include the following information:

a brief description of the breach, including the date of the breach and the date of its discovery, if known;

a description of the type of Unsecured Protected Health Information involved in the breach;

steps you should take to protect yourself from potential harm resulting from the breach;

a brief description of action we are taking to investigate the breach, mitigate losses, and protect against further breaches; and

contact information, including a toll-free number, e-mail address, Website or postal address to permit you to ask questions or obtain additional information.

In the event the breach involves 10 or more patients whose contact information is out of date, we will post a notice of the breach on the home page of our web site or in a major print or broadcast media. If the breach involves more than 500 patients in the state or jurisdiction, we will send notices to prominent media outlets. If the breach involves more than 500 patients, we are required to immediately notify the Secretary of Health and Human Services. We are also required to submit an annual report to the Secretary of a breach that involved less than 500 patients during the year and will maintain a written log of breaches involving less than 500 patients.

Right to an Accounting of Disclosures. You have the right to request an “accounting” of our disclosures of your Protected Health Information. This is a listing of certain disclosures of your Protected Health Information made by the Agency or by others on our behalf, but does not include disclosures made for treatment, payment and health care operations or certain other purposes unless the records are maintained in an Electronic Health Record. Records maintained in an Electronic Health Record will include disclosures made for treatment, payment, health care operations and other purposes.

You must submit a request in writing, stating a time period beginning after April 13, 2003 that is within six years from the date of your request. For example, you may request a list of disclosures the Agency made between January 1, 2004 and January 1, 2005. You are entitled to one free accounting within one 12-month period. For additional requests, we may charge you our costs. Where an Electronic Health Record is used, we will provide you with an accounting of disclosures for a three year period.

We will usually respond to your request within 60 days. Occasionally, we may need additional time to prepare the accounting. If so, we will notify you of our delay, the reason for the delay, and the date when you can expect the accounting.

Right to Request Amendment. If you think that your Protected Health Information is not accurate or complete, you have the right to request that the Agency amend such information for as long as the information is kept in our records. Your request must be in writing and state the reason for the requested amendment. We will usually respond within 60 days, but will notify you within 60 days if we need additional time to respond, the reason for the delay and when you can expect our response. We may deny your request for amendment, and if we do so, we will give you a written denial including the reasons for the denial and an explanation of your right to submit a written statement disagreeing with the denial.

Right to a Paper Copy of This Notice. You have the right to obtain a paper copy of this Notice, even if you have agreed to receive this Notice electronically. You may request a copy of this Notice at any time. [You may obtain a copy of this Notice at our website, www.willcare.com]

Right to Request Confidential Communications. You have the right to request that we communicate with you concerning personal health matters in a certain manner or at a certain location. For example, you can request that we speak to you only at a private location in your home. We will accommodate your reasonable requests.

V. COMPLAINTS

If you believe that your privacy rights have been violated, you may file a complaint in writing with us or with the Office of Civil Rights in the U.S. Department of Health and Human Services. To file a complaint with the Agency, contact our compliance office. No one will retaliate or take action against you for filing a complaint.

VI. CHANGES TO THIS NOTICE

We will promptly revise and distribute this Notice whenever there is a material change to the uses or disclosures, your individual rights, our legal duties, or other privacy practices stated in this Notice. We reserve the right to change this Notice and to make the revised or new Notice provisions effective for all Protected Health Information already received and maintained by the Agency as well as for all Protected Health Information we receive in the future. We will post a copy of the current Notice in the Agency. In addition, we will provide a copy of the revised Notice to all patients by mailing or hand-delivering a hard copy to them or their personal representatives.

VII. FOR FURTHER INFORMATION

If you have any questions about this Notice or would like further information concerning your privacy rights, please contact our compliance office at the number listed.